Consent for HIV Testing
Avenue 360 offers a self-administered screening test for the communicable disease of HIV. I understand that this tests is confidential and that I may have to return in person for conclusive results and subsequent counseling. You must complete this form to indicate that you understand and consent to HIV testing.

I certify that I have received, read, and understand Avenue 360 confidential testing policies:
• If a rapid test was done, an additional sample will need to be collected for confirmatory testing.
• If a test result is positive, I may be referred for more extensive counseling, medical care, and other necessary referrals to help me.
• In the State of Texas, testing for HIV is strictly confidential. However, disclosures can be made to physicians, nurses, or other health care personnel who have a legitimate need to know the test result(s) in order to provide for my health and welfare.
• I give permission for information pertaining to my demographics and test results to be entered into Evaluation Web, Ahlers or DSHS databases. The databases can only be accessed by authorized personnel to assess the system’s provision of services for planning, program development, statistical reporting, and billing purposes.
• I understand I may obtain a copy of Avenue 360 Notice of Privacy Practice that provides a more complete description of information uses and disclosures of my protected health information.
• I further understand that Avenue 360 reserves the right to change their notice and practices prior to implementation in accordance with section 164.520 of the Code of Federal Regulations. Should the agency change their notice, it will send me a copy of any revised notice to the address I’ve provided (whether facsimile, U.S. mail, or if I agree to email).
Legal Name (first, last) *
Preferred Name (if different from legal name)
Address (street, city, state, zip code) *This will be the address that the HIV test kit will be mailed to *
Date of Birth *
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Phone Number *
What is your family size? *
What is your income (estimate) *
Do you have medical insurance? *
If yes, which one *
Checking the following box indicates that you understand and consent to HIV testing and acknowledge that this is your electronic signature. *
Checking the following box indicates that you understand that the HIV test kit will be mailed at the address listed above. You also understand that if you do not live alone, and someone opens your mail, Avenue 360 is nor responsible for any security infractions or intrusions. *
If you would like for us to send the HIV test kit to another address, please provide us with the street address, city, state, and zip code below.
Your HIV Test results will be emailed to you. Please provide us with the email address where you would like to receive your results. *
Checking the following box indicates that you consent to us emailing you your HIV test results confidentially at the email address listed above. *
You consent to HIV testing and understand confidential risks that may occur on this day of: *
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